Provider Demographics
NPI:1033131479
Name:POLLASTRINI, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:POLLASTRINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:1302 FRANKLIN AVE STE 1100
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-0016
Practice Address - Country:US
Practice Address - Phone:309-268-2727
Practice Address - Fax:309-268-6513
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073402Medicaid
5723019OtherBLUE CROSS BLUE SHIELD
ILK30323Medicare ID - Type UnspecifiedMEDICARE PIN TCH
IL036073402Medicaid
ILK30324Medicare ID - Type UnspecifiedMEDICARE PIN INT
IL748942Medicare ID - Type UnspecifiedMEDICARE GROUP LEX
ILK30317Medicare ID - Type UnspecifiedMEDICARE PIN LFM
E17034Medicare UPIN
IL206706Medicare ID - Type UnspecifiedMEDICARE GROUP LFM
IL200871Medicare ID - Type UnspecifiedMEDICARE GROUP INT
IL748943Medicare ID - Type UnspecifiedMEDICARE GROUP EP
ILK30319Medicare ID - Type UnspecifiedMEDICARE PIN EP
ILK30321Medicare ID - Type UnspecifiedMEDICARE PIN FMA
K52728Medicare PIN
5723019OtherBLUE CROSS BLUE SHIELD
IL748940Medicare ID - Type UnspecifiedMEDICARE GROUP HPT
K25466Medicare ID - Type Unspecified
ILK30318Medicare ID - Type UnspecifiedMEDICARE PIN HPT
IL712180Medicare ID - Type UnspecifiedMEDICARE GROUP TCH
ILK30320Medicare ID - Type UnspecifiedMEDICARE PIN LEX